Fields marked with an asterisk (*) are required.
To receive your Assisted Living Administrator renewal license, The below items MUST be faxed (334) 801-9579 or emailed chaustin3@gmail.com by the expiration date of your license.
  • A Copy of NHA license renewal card
  • A Copy of State license of the assisted living facility for which you have administrative responsibility
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*License Number:
*Last 4 of SSN:
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